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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUINSTOCgTON(2CA)95201420 , <br /> P O BOX 2009, x <br />`� PERMIT EgPIRES ] YEAR FROM DATE ISSUFP <br /> (Complete in Triplicate) <br /> Vork <br /> 1 Application is hereby <br /> made to San Joaquin County for a permit to construct and/or9 and instal62 and the Rules hereinand described. Bans <br />` application is made in compliance with San Joaquin County Ordinance No. <br /> Joaquin County Public Health Services. ffiill� t Size/Acreage <br /> ZA( City <br /> Job Address A Phone <br /> ..Z y <br /> l <br /> rl Address �- r <br /> Owner's Name <br /> !` License No � Phone <br /> address 4 <br /> Contractor WELL REPLACEMENT ❑ DESTRUCTION LIOut of Service well. ❑ <br /> � _ xNEW WELL �^'-^rMcnitoring- fell L3 <br /> TYPE OF WELL/PUMP: __ SOTHER ❑ <br /> YST M REPAIR ❑ <br /> PUMP INSTALLATION ❑ DISPOSAL FLO. PROP. LINE <br /> SEWER LINES PITS/SUMPS <br /> ` DISTANCE TO NEAREST: SEPTIC TANK �---�— AGRICULTURE WE L ER WELL_-- <br /> f FOUNDATION ��--- <br /> N SPECIFICATIONS <br /> TY�PE;OF WELL tion PROBLEM AREA CONS. Dia, of Wel! Casing <br /> INTENDED USE -- Di Well Excava <br /> ❑ Open'Bottom ❑ Manteca Specifications <br /> f fl Industrial � _ ype f,,Casing_. <br /> C7 Tracy # Type of Grout <br /> C7 Domestic/Private - Gravel Peck <br /> (I Other <br /> n pelta Dept otlGrout Seal <br /> I'I Public f <br /> Approx. Depth L1 E mSuri ce Seal Installed by <br /> �. <br /> t I i Irrigation H.P. State Work Done _ <br /> Repair Work Done ❑ Type of Pump Sealing Me erial 8 Depth <br /> Well Destruction ❑ Weil Diameter �— —Filler-Ma rial-i.Depth vv <br /> Depth <br /> e within 200 leetJ , <br /> TYPE OF 5EPT1C WORK; NEW INSTALLATION l availabl <br /> REPAIR;11IADDITION i I DESTRUCTION I I INo septic system permitted if public sewer is <br /> Commercial --/'Other <br /> -- <br /> Installation will serve: Residence.� — ; <br /> Number of living units: Number of bedrooms <br /> l Water table depth <br /> Character of soil to a depth of 3 feet: Capacity No. Compartments <br /> SEPTIC TANK. D Type/Mfg +� �..._w----Method of Dispal <br /> PKG. TREATMENT PLT. ❑ �Property Line <br /> Distance to nearest: ' Well oundation <br /> To I length/! r f` <br /> LEACHING LINE ❑ No. & Length of lines _ / �} Property Line `l <br /> n Distance to nearest: Well oundatlo�n_L------- r <br /> FILTER BED a. <br /> s <br /> F =t Nu er �L <br /> k SEEPAGE PITS 11 L3 DepthNu <br /> Property Line <br /> Dial ton est: Well Foundation 0 <br /> SUMPS � ' r ` <br /> k DISPOSAL PONDS ❑ R <br /> i <br /> 1 hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations a the San Joaquin County * following; <br /> Home owner or lien�ucfi merine9ath <br /> s to become subjects to workman's compensation laws of California." Contractor's which <br /> or sub-contracis permit is �nglsignature <br /> employ any person <br /> eenifies the following: "I certify that n the performance of the work for which this permit is issued, i shall employ person6 subject to workman's compens <br /> tion laws of California." <br /> } inspections. Complete drawing on reverse side. <br /> The applifAccepted <br /> for quired inF f 3-� ys <br /> Title: Dale:Signed XFOR EPARTMENT USE ONLY <br /> —()� Area <br /> ate Applicatiy X <br /> �` Date Final Inspection by Date <br /> Pit or Grout Inspection by <br /> �— <br /> i 1 <br /> Additirihal Comments: <br /> ! Applicant - Return all copies to: EnvironmentalCounty <br /> Healthpublic <br /> Permit/SeryServices <br /> ices <br /> --�RX445-N-­San-3oaqui•n P-O-Box_2009,..Stkn,.CA�9S201 ----r— <br /> CK RECEIVED SY PATE PERM[7'NO. <br /> FEE ` <br /> AMOUNT DUE AMOUNT REMITTED CASH C� <br /> INFO <br /> . EN 13.241REV.1/115) 11 -72— <br /> J <br /> EK 14.2E t rI <br />